Denials

Published 02/23/2023

October – December 2022, Outpatient Services Medical Review Top Denial Reason Codes
We encourage all providers to review this information when filing claims to prevent denials and to ensure their claims are processed timely. The following information affects providers billing the 13X bill type in South Carolina, North Carolina, Virginia and West Virginia.

Rank	Denial Code	Denial Description	# Claims
1	55504/55503	No Medical Necessity	4157
2	53NCD/54NCD	No Diagnosis/Documentation to Support Medical Necessity (Bene Liable/ Provider Liable)	4135
3	52NCD	NCD Denial — HCPCS/Diagnosis Matched National Coverage Determination (NCD) Table List ICD9-CM Deny Codes	228
4	5D164/5H164	Documentation Submitted Does Not Support Medical Necessity	224
5	56900	Auto Denial — Requested Records Not Submitted	209
6	5OP70	Service Is Subject to Prior Authorization and No UTN Is Present on the Claim	169
7	5D165/5H165	No Certification	60
8	5OP62	Item of Service Is Subject to Prior Authorization and No Prior Authorization Was Requested for the Item of Service	53

October – December 2022, Inpatient Hospital and Psych Medical Review Top Denial Reason Codes
We encourage all providers to review this information when filing claims to prevent denials and to ensure their claims are processed timely. The following information affects providers billing the 11X bill type in South Carolina, North Carolina, Virginia and West Virginia.

Rank	Denial Code	Denial Description	# Claims
1	56900	Auto Denial — Requested Records not Submitted	34
2	55503	LCD Denial — No Medical Necessity	10
3	5D164	Documentation Submitted Does Not Support Medical Necessity	1
4	5D650	No Valid Certification, Recertification Present	1
5	5D800	Documentation Submitted Does Not Support Medical Necessity for Inpatient Psychiatric Services	1

October – December 2022, Skilled Nursing Facility Medical Review Top Denial Reason Codes
We encourage all providers to review this information when filing claims to prevent denials and to ensure their claims are processed timely. The following information affects providers billing the 21X bill type in South Carolina, North Carolina, Virginia and West Virginia.

Rank	Denial Code	Denial Description	# Claims
1	5D002/5X002	Agree with Provider (Beneficiary Liable)	21
2	5D505	Certification Not Valid	5
3	5DOWN	Medical Review Downcode	5
4	5D504/5H504	Not Medically and Reasonable Necessary	3
5	56900	Auto Denial — Requested Records Not Submitted	2
6	5D510	Skilled Nursing Facility Benefits Are Only Available After an Eligible Covered Hospital Stay of at Least 3 Days	2
7	5D011/5X011	Agree With Provider (Provider Liable)	2
8	55503	LCD Denial — No Medical Necessity	1
9	5D508/5H508	Benefits Are Exhausted on a SNF Claim for Services Subject to Benefit Period Determinations	1

5D505 — Certification Not Valid

Reason for Denial
The certification or recertification is not submitted, not signed, not dated, or does not cover the dates of service in question.

To Prevent This Denial

A certification or recertification statement must be signed by an attending physician or a physician on the staff of the SNF who has knowledge of the case or a nurse practitioner who does not have a direct or indirect employment relationship with the facility, but who is working in collaboration with the physician, or a clinical nurse specialist who does not have a direct or indirect employment relationship with the facility, but who is working in collaboration with the physician. Initial certifications must be obtained at the time of admission, or as soon thereafter as is reasonable and practicable
The routine physician’s admission order is not a certification of the necessity for post-hospital extended care services for purposes of the Medicare program
When responding to a request for copies of medical records, submit the initial certification and/or subsequent recertifications related to the look back periods and the dates of service under review

More Information

CMS Manual System, Publication 100-08, Medicare Program Integrity Manual, Chapter 6 — Intermediary MR Guidelines for Specific Services, Section 6.3 (PDF)
CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 40 (PDF)
Code of Federal Regulations (CFR)
- 42 CFR § 424.11(c) and 424.20, requirements for post-hospital SNF care

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